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PEO Co-Employer Application

Total number of pages:_____________ Fax complete submission to 877.540.0878 Prepared By: Date Submitted Date Needed # of Proposals

Customer Legal Name (Include DBA if necessary) Address City, State & Zip code Phone Number FEIN# Main Contact Name Secondary Contact Title Title SIC Cod e Fax Number NCCI Risk ID# Email Address Email Address Web Site

Please Check One: [ ] C Corp [ ] S Corp [ ] LLC [ ] Partnership [ ] Proprietorship [ ] Non-Profit Unemp. Tax Rate# of Full Time EEs # of Part Time EEs # of Locations Years in Business

Detailed description of business operations

SUBMIT THE FOLLOWING DOCUMENTS WITH YOUR COMPLETED REQUEST FOR PROPOSAL [ ] Workers' compensation declaration page [ ] Three years workers' compensation loss history [ ] Most recent state unemployment tax report Contact Numbers: 954.540.5205 Direct 877-540-0878 - Fax adamcorin@nirocconsultants.com

[ ] If in a PEO relationship copies of billing report dating January and most recent billing report [ ] Detailed employee census to include name, DOB, gender, coverage elected, annual comp [ ] If no prior workers compensation coverage, provide bio on owners

PEO Co-Employer Application


HUMAN RESOURCES/PAYROLL INFORMATION
1. Do you have an employee handbook? [ ] Yes [ ] No If yes, last updated__________ 2. Is the OSHA 200 log posted, filed (Feb) [ ] Yes [ ] No If yes attach copies 3. Have you had employee litigation in the past three years? [ ] Yes [ ] No If yes attach details 4. Do you perform pre-employment screening on applicants? [ ] Yes [ ] No If yes attach types and costs 5. Are compliance postings current? [ ] Yes [ ] No 6. Do employees receive bonuses? [ ] Yes [ ] No 7. Do any employees receive 1099 payments? [ ] Yes [ ] No 8. Do you utilize any staffing companies? [ ] Yes [ ] No If yes, who________________ 9. Do you have tipped employees? [ ] Yes [ ] No 10. Are you a Drug Free Workplace? [ ] Yes [ ] No How is payroll currently executed? [ ] In-house [ ] Payroll company_______________________ [ ] PEO______________________ Payroll Frequency: [ ] Weekly [ ] Bi Weekly [ ] Semi Monthly [ ] Monthly Pay Period End Day:____________________________ Payday:________________________ How much overtime is worked per period? ________ # of W-2s last year:_________________ Amount of wages in excess of FICA SS Max ($106,800 per individual for 2010):$ __________________________ Required payroll reporting? [ ] Departmental [ ] Job Costing [ ] Certified Payroll [ ] Electronic [ ] Other _____________________ Please mark all States in which prospective client maintain employees. Alabama Illinois Montana Alaska Indiana Nebraska Arizona Iowa Nevada * Arkansas Kansas New Hampshire California Kentucky New Jersey Rhode Island South Carolina South Dakota Tennessee Texas

Contact Numbers: 954.540.5205 Direct 877-540-0878 - Fax adamcorin@nirocconsultants.com

Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho * State FundedSt

Louisiana Maine Maryland Massachusett s Michigan Minnesota Mississippi Missouri

New Mexico New York North Carolina North Dakota * Ohio * Oklahoma Oregon Pennsylvania

Utah Vermont Virginia Washington * West Virginia * Wisconsin Wyoming *

PEO Co-Employer Application


OCCUPATIONAL RISK EVALUATION
Current Carrier: ____________________________ Renewal Date: _______________ Current Experience Modifier: ______________ Special Credits: _________% _________% Policy Type: _____________________________________________________ Stat Description Class Code $ $ $ $ $ Check YES or NO and attach details of any "YES" answers: 1. Do you own, operate or lease aircraft/watercraft? [ ] Yes [ ] No 2. Any exposure to flammable, explosive or caustic fumes? [ ] Yes [ ] No 3. Any work performed above/underground 10 feet? [ ] Yes [ ] No 4. Any work performed on barges, vessels, or docks? [ ] Yes [ ] No 5. Are there any other businesses involved? [ ] Yes [ ] No 6. Are sub-contractors used? [ ] Yes [ ] No 7. Is a formal safety plan in operation? [ ] Yes [ ] No 8. Any group transportation provided to employees? [ ] Yes [ ] No 9. Any seasonal help? [ ] Yes [ ] No 10. Do employees travel out of state for longer than 90 days? [ ] Yes [ ] No 11. Any coverage declined, cancelled or non-renewed in the last 3 years? [ ] Yes [ ] No Contact Numbers: 954.540.5205 Direct 877-540-0878 - Fax adamcorin@nirocconsultants.com Annual Payroll FT EEs PT EEs Company Use Only Other:

12. 13. 14. 15. 16. 17. 18.

Are there any unusual working conditions? [ ] Yes [ ] No Service provided 24 hours a day [ ] Yes [ ] No Major operations outside the state [ ] Yes [ ] No Heavy equipment (Ex. cranes, bulldozers, cherry pickers) [ ] Yes [ ] No Home health care [ ] Yes [ ] No Armed guards [ ] Yes [ ] No Pest control [ ] Yes [ ] No

PEO Co-Employer Application


Controlling Person First Name: Address City, State & Zip Last Name: Phone Number

Payment Type Requested (Check One): [ ] Automatic Debit [ ] Certified Funds [ ] Wire Transfer Co-Owner First Name: Address City, State & Zip Last Name: Phone Number

I understand a proposal cannot be generated unless application is complete. I hereby certify that all answers and information on this request for proposal are true and accurate to the best of my knowledge. I understand that any information found to be false or if any representations are found to be false it is grounds for termination of the Client Service Agreement to include cancellation of any and all coverage(s) extended. Submitting this request for proposal is in no way a guarantee of acceptance. ______________________________________________________________________________________ Controlling Person Name Signature Date ______________________________________________________________________________________ Co-Owner Name Signature Date ______________________________________________________________________________________ Account Executive Name Signature Date

Contact Numbers: 954.540.5205 Direct 877-540-0878 - Fax adamcorin@nirocconsultants.com

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